Online Admission Form - Reliant Physical Therapy

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Date	08/26/2025
Patient Information
Formal Name (as on Insurance Card or Driver License)	Stephanie L Fleming
Nickname/Name you liked to be called?	Queen 🤣
Gender	Female
Date of Birth	05/06/1976
Email	Email hidden; Javascript is required.
Address	199 Vernon Jones Avenue 211-23 Brandon, Mississippi 39047 Map It
Home Phone	(601) 937-0452
Would you like an email or text message reminder about your appointments?	Yes
What type of reminder(s) would you like?	Text Message (2-3 hrs prior to appointment)
Which clinic will you receive treatment at?	Flowood
Guarantor Information
Patient Relationship to Guarantor.	Self
Insurance Information
Primary Insurance	Mississippi Medicaid
Primary Insurance ID Number	740613006
Primary Insurance: Patient's Relationship to Insured Party	Self
Primary Insurance: Insured Party Name	Stephanie L Fleming
Primary Insurance: Insured Party DOB	05/06/1976
Primary Insurance: Insured Party Gender	Male
Primary Insurance: Insured Address	199 Vernon Jones Avenue 211-23 Brandon, Mississippi 39047 Map It
Do you have a secondary Insurance.	Yes
Secondary Insurance	Magnolia Health
Secondary Insurance ID Number	740613006
Secondary Insurance: Patient's Relationship to Insured Party	Self
Secondary Insurance: Insured Phone	(601) 937-0452
Secondary Insurance: Insured Party DOB	05/06/1976
Secondary Insurance: Insured Party Gender	Male
Secondary Insurance: Insured Address	199 Vernon Jones Avenue 211-23 Brandon, Mississippi 39047 Map It
Is this a worker's compensation or other accident claim?	No
Emergency Contacts
Emergency Contact 1: Name	Sigrid Garner
Emergency Contact 1: Phone Number	(601) 940-3700
Emergency Contact 2: Name	Hughes Fleming
Emergency Contact 2: Phone Number	(601) 850-1069
Basic Information
What part of your body will we be treating today? (hip, knee, back...)	Knee
What side of the body will we be treating?	Right
Date of Injury or when your pain began.	03/10/2024
Is this injury due to:	Degenerative disk/spondylisis
Patient Maritial Status	Other
Briefly describe your symptoms:	Extreme Pain walking or putting weight on leg. Bending knee certain ways, pain and throbbing if I am vertical for too long.
How did your symptoms start?	Just mild pain when walking progressively got worse
What is your biggest complaint?	Terrible pain and not being able to do what I need to
How often do you experience your symptoms?	Constantly (76-100% of the time)
Did you have surgery?	No
Rate your overall health:	Good
Living Situation	Lives with Family
Do you now or have you ever smoked?	Yes
How many years did or have you smoked?	3
On average, about how many packs per day did or do you smoke?	Don’t remember not even hall a pack. I quit 15 years ago
Do you have a history of falling?	No
Have you had prior physical therapy, occupational therapy or chiropractic treatment this year?	No
Current Functional Limitations
How much have your symptoms interfered with your usual daily activities	Quite a Bit
Please check or describe any limitations you have experienced in your Self Care:	Sleeping Dressing Chores Caregiving
Please check or describe any limitations you have experienced in your Mobility:	Walking at Home Food Prep Housekeeping Laundry Negotiating Obstacles Shopping
Please check or describe any limitations you have experienced in your ability to Change and Move Body Positions:	Prolonged Standing Kneeling Squatting Housekeeping Laundry
Please check or describe any limitations you have experienced in your ability to Carry, Move and Handle Objects:	Work/Vocation/Occupation Recreation Kicking/Pushing with Legs
Pain
Where is the location of your pain?	Knee
What is the WORST your pain gets on a 0 - 10 Scale?	10/10 - Severe Pain
What is the BEST your pain gets on a 0 - 10 Scale?	4/10
What is your pain RIGHT NOW on a 0 - 10 Scale?	7/10
Pain Description (Please check all that apply)	Sharp Throbbing Shooting Intermittent Worse in PM Worse at night while sleeping
What makes your pain worse?	Standing Walking Going Up Stairs Going Down Stairs Standing Bending
What makes your pain better?	Ice/head/meds
Employment
Are you employed?	No
Are you disabled or currently on disability?	No
What doctor referred you to therapy?	Christine Watson-capital ortho
Medical History
Do you have any of the following medical conditions? (Check all that apply)	Cauda Equina Obesity Osteoarthritis Fibromyalgia High Blood Pressure
Have you had any diagnostic imaging studies for this injury?	X-Ray
Have you had any recent or unexplained weight loss?	No
Are you taking any of the following?	Prescription Medications Over the Counter Medications Vitamin/Mineral/Dietary Supplements
Please list the Prescriptions Medications you are taking. You may bring in a list if you prefer to do so.	Metoprolol, linsinipril/HCTZ, unithroid, lyrica, Prozac, Wellbutrin, protonix, lyrica, tramadol(as needed),Robaxin (as needed), adipex
Please list the Over the Counter Medications you are taking. You may bring in a list if you prefer to do so.	Advil
Please list the Vitamin/Mineral/Dietary Supplements you are taking. You may bring in a list if you prefer to do so.	Multivitamin
Please list any allergies you may have and your bodies response to this allergy.	Iodine
Please list any relevant surgeries you have had in the past. (Include side of the body and approximate date.)	Surgery to remove bone due to cauda equina syndrome 2022
What are your goals from physical therapy?	Satisfy insurance so I can have a knee replacement. Maybe less pain in the meantime
Please list a primary functional activity that you have difficulty performing.	stairs
How much difficulty do you have in performing this first task?	8/10
Please list a second functional activity that you have difficulty performing.	Walking
How much difficulty do you have in performing this second task?	5/10 - Moderate Difficulty
Please list a third functional activity that you have difficulty performing.	Standing for any links of time
How much difficulty do you have in performing this third task?	7/10
Are you currently receiving home health services?	No
Consent for Treatment
Consent for Treatment	I, the patient/guardian, acknowledge that I am of a sound mind and physically/mentally able to give consent for my/my dependent's care. I hereby give consent to receive outpatient physical therapy services as deemed necessary by the therapist(s) on duty at Reliant, Inc. I am aware that the practice of physical therapy is not an exact science and I acknowledge that no guarantees have been made regarding my treatments, results or outcomes. I understand that in some cases, treatment techniques may actually increase my pain. I understand that proper evaluation and treatment may require bodily contact, touching and/or direct contact by the therapists. I have reviewed the Patient Consent Form, Dry Needling Consent Form and Privacy Policy at the hyperlinks below. I am aware that as the patient/guardian I have the right to decline and/or refuse any portion of my treatment that I decide not to participate in.
ELECTRONIC MONTHLY NEWSLETTER:
Electronic Monthly Newsletter	In an ongoing effort to provide our patients with continued education and the latest healthcare information you may choose to receive monthly emails from our company. You may opt-out at any time, if you prefer to receive our monthly newsletter please sign up above on our online admission form.
Referral Source
How did you find out about us?	Doctor
Certification Statement
Patient/Guardian Signature	By signing below, I certify that I am the patient or have legal rights to sign on the patient's behalf. Furthermore, I have read and understand the statements and policies that have been stated above. I also certify that I have provided correct information to the best of my knowledge. I hereby authorize payment directly to Reliant, Inc. for medical services rendered. I authorize the release of my medical information deemed necessary in the processing of my medical claims.
Form Completed By;	Stephanie Fleming
Signature